Comprehensive Care and Integration Specialist (CCIS) Team
Supporting clients with complex health needs through an integrated approach to care.
Quick facts
Service type: Health & Wellness
Eligibility: Adults 18+ with complex health conditions residing in mid-East/East Toronto. For additional considerations, please see below.
Delivery: In person, virtual, phone
Fee: Free
Partners: East Toronto Health Partners, COTA, St. Michael's Homes, Michael Garron Hospital
Program description
WoodGreen’sclinical social workers strive to fill gaps in care for clients living with complex health and psychosocial issues. Our Comprehensive Care and Integration Specialistsconnect clients to essentialservices and supports;coordinate follow-up care;and providecase management, counsellingand advocacy on housing, legal, financial and immigration issues.
We work with clients to develop individual Coordinated Care Plans and support their care providers to work as a team. Our goal is to bridge the gap between acute and medical care providersand the community sector.
Eligibility
Patients/clients with significant gaps in care
Patients/clients who may struggle to follow up on care recommendations
Patients/clients who have a history of multiple Emergency Department (ED) visits, are Alternate Level of Care (ALC) or at risk for ongoing visits and in-patient stays
Patients/clients who experience challenges related to the social determinants of health (e.g., housing, income)
Patients/clients who would benefit from integrating the work of multiple health providers
Please consider referring clients with complex health needs from the following groups:
Individuals experiencing mental health and/or addiction issues
Psychogeriatric populations (55+ with mental health and/or addiction issues)
Frail elderly
How you can support
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In person, virtual, on the phone
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In-person, virtual, on the phone
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